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HESI RN EXIT EXAM QUESTIONS AND ANSWERS
In planning care for a 6 month-old infant, what must the nurse provide to assist in the development of trust? A) Food B) Warmth C) Security D) Comfort ... [Show More] - correct answer C) Security A nurse has just received a medication order which is not legible. Which statement best reflects assertive communication? A) "I cannot give this medication as it is written. I have no idea of what you mean." B) "Would you please clarify what you have written so I am sure I am reading it correctly?" C) "I am having difficulty reading your handwriting. It would save me time if you would be more careful." D) "Please print in the future so I do not have to spend extra time attempting to read your writing." - correct answer B) "Would you please clarify what you have written so I am sure I am reading it correctly?" What is the most important consideration when teaching parents how to reduce risks in the home? A) Age and knowledge level of the parents B) Proximity to emergency services C) Number of children in the home D) Age of children in the home - correct answer D) Age of children in the home A 35 year-old client with sickle cell crisis is talking on the telephone but stops as the nurse enters the room to request something for pain. The nurse should A) Administer a placebo B) Encourage increased fluid intake C) Administer the prescribed analgesia D) Recommend relaxation exercises for pain control - correct answer C) Administer the prescribed analgesia While caring for a toddler with croup, which initial sign of croup requires the nurse's immediate attention? A) Respiratory rate of 42 B) Lethargy for the past hour C) Apical pulse of 54 D) Coughing up copious secretions - correct answer A) Respiratory rate of 42 A client is admitted with low T3 and T4 levels and an elevated TSH level. On initial assessment, the nurse would anticipate which of the following assessment findings? A) Lethargy B) Heat intolerance C) Diarrhea D) Skin eruptions - correct answer A) Lethargy The emergency room nurse admits a child who experienced a seizure at school. The father comments that this is the first occurrence, and denies any family history of epilepsy. What is the best response by the nurse? A) "Do not worry. Epilepsy can be treated with medications." B) "The seizure may or may not mean your child has epilepsy." C) "Since this was the first convulsion, it may not happen again." D) "Long term treatment will prevent future seizures." - correct answer B) "The seizure may or may not mean your child has epilepsy." Alcohol and drug abuse impairs judgment and increases risk taking behavior. What nursing diagnosis best applies? A) Risk for injury B) Risk for knowledge deficit C) Altered thought process D) Disturbance in self-esteem - correct answer A) Risk for injury Which these findings would the nurse more closely associate with anemia in a 10 month-old infant? A) Hemoglobin level of 12 g/dI B) Pale mucosa of the eyelids and lips C) Hypoactivity D) A heart rate between 140 to 160 - correct answer B) Pale mucosa of the eyelids and lips The nurse is caring for a client in hypertensive crisis in an intensive care unit. The priority assessment in the first hour of care is A) Heart rate B) Pedal pulses C) Lung sounds D) Pupil responses - correct answer D) Pupil responses Which of these clients who are all in the terminal stage of cancer is least appropriate to suggest the use of patient controlled analgesia (PCA) with a pump? A) A young adult with a history of Down's syndrome B) A teenager who reads at a 4th grade level C) An elderly client with numerous arthritic nodules on the hands D) A preschooler with intermittent episodes of alertness - correct answer D) A preschooler with intermittent episodes of alertness The nurse is about to assess a 6 month-old child with nonorganic failure-to thrive (NOFTT). Upon entering the room, the nurse would expect the baby to be A) Irritable and "colicky" with no attempts to pull to standing B) Alert, laughing and playing with a rattle, sitting with support C) Skin color dusky with poor skin turgor over abdomen D) Pale, thin arms and legs, uninterested in surroundings - correct answer D) Pale, thin arms and legs, uninterested in surroundings As the nurse is speaking with a group of teens which of these side effects of chemotherapy for cancer would the nurse expect this group to be more interested in during the discussion? A) Mouth sores B) Fatigue C) Diarrhea D) Hair loss - correct answer D) Hair loss While caring for a client who was admitted with myocardial infarction (MI) 2 days ago, the nurse notes today's temperature is 101.1 degrees Fahrenheit (38.5 degreesCelsius). The appropriate nursing intervention is to A) Call the health care provider immediately B) Administer acetaminophen as ordered as this is normal at this time C) Send blood, urine and sputum for culture D) Increase the client's fluid intake - correct answer B) Administer acetaminophen as ordered as this is normal at this time A client is admitted for first and second degree burns on the face, neck, anterior chest and hands. The nurse's priority should be A) Cover the areas with dry sterile dressings B) Assess for dyspnea or stridor C) Initiate intravenous therapy D) Administer pain medication - correct answer B) Assess for dyspnea or stridor Which of these clients who call the community health clinic would the nurse ask to come in that day to be seen by the health care provider? A) I started my period and now my urine has turned bright red. B) I am an diabetic and today I have been going to the bathroom every hour. C) I was started on medicine yesterday for a urine infection. Now my lower belly hurts when I go to the bathroom. D) I went to the bathroom and my urine looked very red and it didn't hurt when I went. - correct answer D) I went to the bathroom and my urine looked very red and it didn't hurt when I went. Which of these parents' comment for a newborn would most likely reveal an initial finding of a suspected pyloric stenosis? A) I noticed a little lump a little above the belly button. B) The baby seems hungry all the time. C) Mild vomiting that progressed to vomiting shooting across the room. D) Irritation and spitting up immediately after feedings. - correct answer C) Mild vomiting that progressed to vomiting shooting across the room. The nurse is assessing a child for clinical manifestations of iron deficiency anemia. Which factor would the nurse recognize as cause for the findings? A) Decreased cardiac output B) Tissue hypoxia C) Cerebral edema D) Reduced oxygen saturation - correct answer B) Tissue hypoxia The nurse would expect the cystic fibrosis client to receive supplemental pancreatic enzymes along with a diet A) High in carbohydrates and proteins B) Low in carbohydrates and proteins C) High in carbohydrates, low in proteins D) Low in carbohydrates, high in proteins - correct answer A) High in carbohydrates and proteins In evaluating the growth of a 12 month-old child, which of these findings would the nurse expect to be present in the infant? A) Increased 10% in height B) 2 deciduous teeth C) Tripled the birth weight D) Head > chest circumference - correct answer C) Tripled the birth weight A Hispanic client in the postpartum period refuses the hospital food because it is "cold." The best initial action by the nurse is to A) 1Have the unlicensed assistive personnel (UAP) reheat the food if the client wishes B) Ask the client what foods are acceptable or bad C) Encourage her to eat for healing and strength D) Schedule the dietitian to meet with the client as soon as possible - correct answer B) Ask the client what foods are acceptable or bad The father of an 8 month-old infant asks the nurse if his infant's vocalizations are normal for his age. Which of the following would the nurse expect at this age? A) Cooing B) Imitation of sounds C) Throaty sounds D) Laughter - correct answer B) Imitation of sounds The nurse should recognize that physical dependence is accompanied by what findings when alcohol consumption is first reduced or ended? [Show Less]
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HESI EXIT EXAM - EVOLVE QUESTIONS
What is an example of a type I hypersensitivity reaction? A. Anaphylaxis B. Serum Sickness C. Contact Dermatitis D. Blood transfusion reaction - cor... [Show More] rect answer C. Contact Dermatitis An example of a type I hypersensitivity reaction is anaphylaxis. Serum sickness is a type III immune complex reaction. Contact dermatitis is a type IV delayed hypersensitivity reaction. A blood transfusion reaction is a type II cytotoxic reaction. Inhalation Anthrax Clinical Manifestations A. Fever B. Fatigue C. Rhinitis D. Dry Cough E. Sore throat - correct answer Fever Fatigue Dry Cough Mild chest pain Which type of immunity will clients acquire through immunizations with live or killed vaccines? 1 Natural active immunity 2 Artificial active immunity 3 Natural passive immunity 4 Artificial passive immunity - correct answer 2 - Artificial active immunity is acquired through immunization with live or killed vaccines. Natural active immunity is acquired when there is natural contact with antigens through a clinical infection. Natural passive immunity is acquired through the transfer of colostrums from mother to child. Artificial passive immunity is acquired by injecting serum from an immune human. Which cytokine increases growth and maturation of myeloid stem cells?1.Interleukin-2 2. Thrombopoietin 3. Granulocyte colony-stimulating factor 4. Granulocyte-macrophage colony-stimulating factor - correct answer 4. Granulocyte-macrophage colony-stimulating factor is a cytokine that increases growth and maturation of myeloid stem cells. Interleukin-2 is a cytokine that increases growth and differentiation of T-lymphocytes. Thrombopoietin is a cytokine that increases growth and differentiation of platelets. Granulocyte colony-stimulating factor is a cytokine that increases numbers and maturity of neutrophils. Which autoimmune disease is directly related to the client's central nervous system? A. Rheumatic Fever B. MS C. Myasthenia Gravis D. Good pasture syndrome - correct answer Multiple Sclerosis Which type of hepatitis spreads through contaminated food and water? A. hep a b. hep b c. hep c d. hep d - correct answer a - b, c, d - spread through blood What are the sx of tuberculosis ? A. fatigue B. nausea C. weight gain d. low grade fever e. increased apetite - correct answer A, B, D. fatigue nausea low grade fever weight loss Which type of immunity is acquired through the transfer of colostrum from the mother to the child? 1 Natural active immunity 2 Artificial active immunity 3 Natural passive immunity 4 Artificial passive immunity - correct answer Natural passive immunity is acquired through the transfer of colostrum from the mother to the child. Natural active immunity is acquired when there is a natural contact with an antigen through a clinical infection. Artificial active immunity is acquired through immunization with an antigen. Artificial passive immunity is acquired by injecting serum from an immune human. What does grade 3 indicate according to the muscle-strength scale? 1 Active movement against gravity and some resistance 2 Active movement of body part with elimination of gravity 3 Active movement against full resistance without evident fatigue 4 Active movement against gravity only and not against resistance - correct answer According to the muscle-strength scale, a score of 3 indicates active movement against gravity only and not against resistance. A score of 4 indicates active movement against gravity and some resistance. A score of 2 indicates active movement of a body part with elimination of gravity. A score of 5 indicates active movement against full resistance without evident fatigue. What type of hypersensitivity reaction is the cause of systemic lupus erythematosus? 1 Type I 2 Type II 3 Type III 4 Type IV - correct answer Systemic lupus erythematosus is an example of an immune complex-mediated, or type III, hypersensitive reaction. Anaphylaxis is an example of a type I or immediate hypersensitive reaction. Cytotoxic or type II hypersensitive reactions can result in conditions such as myasthenia gravis and Goodpasture syndrome. Graft rejection and sarcoidosis are conditions that are caused by delayed or type IV hypersensitivity reactions. nurse is teaching a client about human immunodeficiency virus (HIV). What are the various ways HIV is transmitted? Select all that apply. 1 Mosquito bites 2 Sharing syringe needles 3 Breastfeeding a newborn 4 Dry kissing the infected partner 5 Anal intercourse - correct answer Fluids such as blood and semen are highly concentrated with human immunodeficiency virus (HIV). HIV may be transmitted parenterally by sharing needles and postnatally through breast milk. HIV may also be transmitted through anal intercourse. HIV is not transmitted by mosquito bites or dry kissing. the nurse is caring for a client with a respiratory tract infection that started with a common cold but has progressed to whooping cough. The client also has coughing fits that last for several minutes. Which organism is responsible for the client's condition? 1 Bacillus anthracis 2 Bordetella pertussis 3 Streptococcus pneumoniae 4 Mycobacterium tuberculosis - correct answer This disease is caused by Bordetella pertusis. Pertussis is a respiratory tract infection that begins with the common cold and progresses to whooping cough. The client also develops coughing fits that last for several minutes. Which symptoms are common during the fulminant stage of inhalation of anthrax? Select all that apply. 1 Dyspnea 2 Dry cough 3 Diaphoresis 4 Mild chest pain 5 High temperature - correct answer dyspnea diaphoresis high temp (prodromal phase will have dry cough and mild chest pain) A client with cirrhosis of the liver and ascites has been taking chlorothiazide, a thiazide diuretic. Why did the provider add spironolactone to the client's medication regimen? 1 To stimulate sodium excretion 2 To help prevent potassium loss 3 To increase urine specific gravity 4 To reduce arterial blood pressure - correct answer 2 - to help prevent potassium loss spirnolactone is a potassium sparing diuretic used in conjunction with thiazide diuretics. The provider was prompted to add spironolactone to the chlorothiazide to prevent potassium loss. Both medications stimulate sodium excretion. Both medications increase urine specific gravity and reduce arterial blood pressure. A client who is recuperating from a spinal cord injury at the T4 level wants to use a wheelchair. What should the nurse teach the client to do in preparation for this activity? 1 Push-ups to strengthen arm muscles 2 Leg lifts to prevent hip contractures 3 Balancing exercises to promote equilibrium 4 Quadriceps-setting exercises to maintain muscle tone - correct answer 1 -Arm strength is necessary for transfers and activities of daily living and for use of crutches or a wheelchair, so the nurse should teach the client how to do wheelchair push-ups safely. Equilibrium is not a problem. The client does not have neurologic control of the other activities. A nurse administers leucovorin calcium to a client before the prescribed methotrexate. The client asks the reason for this. What effect of leucovorin calcium should the nurse consider when formulating a response? 1 Supplies levels of folic acid required by blood-forming organs 2 Potentiates metabolite required for destruction of cancer cells 3 Acts synergistically with antineoplastic drugs to destroy cancer cells 4 Increases production of phagocytes to help remove debris from destroyed cancer cells - correct answer 1- Methotrexate is a folic acid antagonist that can depress the bone marrow; this serious toxic effect sometimes is prevented by administration of folic acid. Some healthcare providers advocate its administration after a course of methotrexate therapy to avoid interfering with methotrexate activity. The nurse is providing discharge teaching to the parents of a 3-day-old infant. The mother expresses concern regarding sudden infant death syndrome (SIDS). To reduce the risk of SIDS during sleep, how does the nurse instruct the parents to position the infant? 1 Prone 2 Supine 3 Side-lying 4 Next to an adult in bed for closer monitoring - correct answer Supine - 2 - provides for maximal air movement A client will be discharged with a peripherally inserted central venous catheter (PICC) for administration of peripheral parenteral nutrition (PPN). What would be appropriate for the nurse to include in the client's discharge teaching? 1 Learning how to change the percutaneous catheter 2 Determining which days to self-administer the PPN solution 3 Arranging for professional help to monitor the alternative nutrition 4 Scheduling administration of the PPN solution around mealtimes - correct answer 3- Professional assistance will ensure correct administration, which may limit complications such as intravascular overload and sepsis; eventually, the client may self-administer the PPN with supervision. Learning how to change the percutaneous catheter usually is done by an appropriate health care provider. PPN usually is administered every day. The PPN solution usually is administered as an intermittent infusion while the client is sleeping at night, not at mealtimes; this allows for independent movement during the day. Which urinary diagnostic test does not require any dietary or activity restrictions for the client before or after the test? 1 Renal scan 2 Renal biopsy 3 Renal arteriogram 4 Concentration test - correct answer A renal scan does not require any dietary or activity restrictions. A renal biopsy requires bed rest for 24 hours after the procedure. A renal arteriogram requires the client to maintain bed rest with affected leg straight. A concentration test requires the client to fast after a given time in the evening. What should a nurse teach a nonbreastfeeding mother to help relieve the discomfort of engorgement? 1 Empty the breasts manually once a day. 2 Apply cold packs to the breasts frequently. 3 Ask the practitioner to prescribe a medication for pain. 4 Loosen the brassiere until the breast swelling has subsided. - correct answer 2 A client with acute kidney injury states, "Why am I twitching and my fingers and toes tingling?" Which process should the nurse consider when formulating a response to this client? 1 Acidosis 2 [Show Less]
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EXIT HESI 700 QUESTIONS
Following discharge teaching, a male client with duodenal ulcer tells the nurse the he will drink plenty of dairy products, such as milk, to help coat and ... [Show More] protect his ulcer. What is the best follow-up action by the nurse? - correct answer Review with the client the need to avoid foods that are rich in milk and cream A male client with hypertension, who received new antihypertensive prescriptions at his last visit returns to the clinic two weeks later to evaluate his blood pressure (BP). His BP is 158/106 and he admits that he has not been taking the prescribed medication because the drugs make him "feel bad". In explaining the need for hypertension control, the nurse should stress that an elevated BP places the client at risk for which pathophysiological condition? - correct answer Stroke secondary to hemorrhage The nurse observes an unlicensed assistive personnel (UAP) positioning a newly admitted client who has a seizure disorder. The client is supine and the UAP is placing soft pillows along the side rails. What action should the nurse implement? - correct answer Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillows An adolescent with major depressive disorder has been taking duloxetine (Cymbalta) for the past 12 days. Which assessment finding requires immediate follow-up - correct answer Describes life without purpose A 60-year-old female client with a positive family history of ovarian cancer has developed an abdominal mass and is being evaluated for possible ovarian cancer. Her Papanicolau (Pap) smear results are negative. What information should the nurse include in the client's teaching plan - correct answer Further evaluation involving surgery may be needed A client who recently underwent a tracheostomy is being prepared for discharge to home. Which instructions is most important for the nurse to include in the discharge plan? - correct answer Teach tracheal suctioning techniques In assessing an adult client with a partial rebreather mask, the nurse notes that the oxygen reservoir bag does not deflate completely during inspiration and the client's respiratory rate is 14 breaths / minute. What action should the nurse implement - correct answer Document the assessment data Rational: reservoir bag should not deflate completely during inspiration and the client's respiratory rate is within normal limits. During shift report, the central electrocardiogram (EKG) monitoring system alarms. Which client alarm should the nurse investigate first? - correct answer Respiratory apnea of 30 seconds During a home visit, the nurse observed an elderly client with diabetes slip and fall. What action should the nurse take first? - correct answer Check the client for lacerations or fractures At 0600 while admitting a woman for a schedule repeat cesarean section (C-Section), the client tells the nurse that she drank a cup a coffee at 0400 because she wanted to avoid getting a headache. Which action should the nurse take first? - correct answer Inform the anesthesia care provider After placing a stethoscope as seen in the picture, the nurse auscultates S1 and S2 heart sounds. To determine if an S3 heart sound is present, what action should the nurse take first - correct answer Listen with the bell at the same location A 66-year-old woman is retiring and will no longer have a health insurance through her place of employment. Which agency should the client be referred to by the employee health nurse for health insurance needs? - correct answer Medicare A client who is taking an oral dose of a tetracycline complains of gastrointestinal upset. What snack should the nurse instruct the client to take with the tetracycline? - correct answer Toasted wheat bread and jelly Following a lumbar puncture, a client voices several complaints. What complaint indicated to the nurse that the client is experiencing a complication? - correct answer "I have a headache that gets worse when I sit up" An elderly client seems confused and reports the onset of nausea, dysuria, and urgency with incontinence. Which action should the nurse implement - correct answer Obtain a clean catch mid-stream specimen The nurse is assisting the mother of a child with phenylketonuria (PKU) to select foods that are in keeping with the child's dietary restrictions. Which foods are contraindicated for this child? - correct answer Foods sweetened with aspartame Before preparing a client for the first surgical case of the day, a part-time scrub nurse asks the circulating nurse if a 3 minute surgical hand scrub is adequate preparation for this client. Which response should the circulating nurse provide? - correct answer Direct the nurse to continue the surgical hand scrub for a 5 minute duration Which breakfast selection indicates that the client understands the nurse's instructions about the dietary management of osteoporosis? - correct answer Bagel with jelly and skim milk The charge nurse of a critical care unit is informed at the beginning of the shift that less than the optimal number of registered nurses will be working that shift. In planning assignments, which client should receive the most care hours by a registered nurse (RN) - correct answer An 82-year-old client with Alzheimer's disease newly-fractures femur who has a Foley catheter and soft wrist restrains applied A mother brings her 6-year-old child, who has just stepped on a rusty nail, to the pediatrician's office. Upon inspection, the nurse notes that the nail went through the shoe and pierced the bottom of the child's foot. Which action should the nurse implement first? - correct answer Cleanse the foot with soap and water and apply an antibiotic ointment The mother of an adolescent tells the clinic nurse, "My son has athlete's foot, I have been applying triple antibiotic ointment for two days, but there has been no improvement." What instruction should the nurse provide? - correct answer Stop using the ointment and encourage complete drying of the feet and wearing clean socks. A 26-year-old female client is admitted to the hospital for treatment of a simple goiter, and levothyroxine sodium (Synthroid) is prescribed. Which symptoms indicate to the nurse that the prescribed dosage is too high for this client? The client experiences - correct answer Palpitations and shortness of breath A client with a history of heart failure presents to the clinic with a nausea, vomiting, yellow vision and palpitations. Which finding is most important for the nurse to assess to the client? - correct answer Obtain a list of medications taken for cardiac history The healthcare provider prescribes an IV solution of isoproterenol (Isuprel) 1 mg in 250 ml of D5W at 300 mcg/hour. The nurse should program the infusion pump to deliver how many ml/hour? (Enter numeric value only.) - correct answer 75 Rationale: Convert mg to mcg and use the formula D/H x Q. 300 mcg/hour / 1,000 mcg x 250 ml = 3/1 x 25 = 75 ml/hour The pathophysiological mechanism are responsible for ascites related to liver failure? (Select all that apply) - correct answer -Fluid shifts from intravascular to interstitial area due to decreased serum protein -Increased hydrostatic pressure in portal circulation increases fluid shifts into abdomen -Increased circulating aldosterone levels that increase sodium and water retention The nurse is auscultating a client's heart sounds. Which description should the nurse use to document this sound? (Please listen to the audio first to select the option that applies) - correct answer Murmur The healthcare provider prescribes celtazidime (Fortax) 35 mg every 8 hours IM for an infant. The 500 mg vial is labeled with the instruction to add 5.3 ml diluent to provide a concentration of 100 mg/ml. How many ml should the nurse administered for each dose? (Enter numeric value only. If rounding is required, round to the nearest tenth - correct answer 0.4 rationale: 35mg/100mg x 1 = 0.35 = 0.4 ml The nurse notes that a client has been receiving hydromorphone (Dilaudid) every six hours for four days. What assessment is most important for the nurse to complete? - correct answer Auscultate the client's bowel sounds Rationale: hydromorphone is a potent opioid analgesic that slows peristalsis and frequently causes constipation, so it is most important to Auscultate the client's bowel sounds A female client is admitted with end stage pulmonary disease is alert, oriented, and complaining of shortness of breath. The client tells the nurse that she wants "no heroic measures" taken if she stops breathing, and she asks the nurse to document this in her medical record. What action should the nurse implement - correct answer Ask the client to discuss "do not resuscitate" with her healthcare provider A client is receiving a full strength continuous enteral tube feeding at 50 ml/hour and has developed diarrhea. The client has a new prescription to change the feeding to half strength. What intervention should the nurse implement? - correct answer Add equal amounts of water and feeding to a feeding bag and infuse at 50ml/hour A female client reports that her hair is becoming coarse and breaking off, that the outer part of her eyebrows have disappeared, and that her eyes are all puffy. Which follow-up question is best for the nurse to ask? - correct answer Have you noticed any changes in your fingernails? Rationale: The pattern of reported manifestations is suggestive of hypothyroidism After a third hospitalization 6 months ago, a client is admitted to the hospital with ascites and malnutrition. The client is drowsy but responding to verbal stimuli and reports recently spitting up blood. What assessment finding warrants immediate intervention by the nurse? - correct answer Capillary refill of 8 seconds After the nurse witnesses a preoperative client sign the surgical consent form, the nurse signs the form as a witness. What are the legal implications of the nurse's signature on the client's surgical consent form? (Select all that apply) - correct answer -The client voluntarily grants permission for the procedure to be done -The client is competent to sign the consent without impairment of judgment -The client understands the risks and benefits associated with the procedure Following surgery, a male client with antisocial personality disorder frequently requests that a specific nurse be assigned to his care and is belligerent when another nurse is assigned. What action should the charge nurse implement? - correct answer Advise the client that assignments are not based on clients requests A client with cervical cancer is hospitalized for insertion of a sealed internal cervical radiation implant. While providing care, the nurse finds the radiation implant in the bed. What action should the nurse take? - correct answer Place the implant in a lead container using long-handled forceps The client with which type of wound is most likely to need immediate intervention by the nurse? - correct answer Laceration Rationale: A laceration is a wound that is produced by the tearing of soft body tissue. This type of wound is often irregular and jagged. A laceration wound is often contaminated with bacteria and debris from whatever object caused the cut The nurse is planning care for a client admitted with a diagnosis of pheochromocytoma. Which intervention has the highest priority for inclusion in this client's plan of care? - correct answer Monitor blood pressure frequently Rationale: A pheochromocytoma is a rare, catecholamine-secreting tumor that may precipitate life-threatening hypertension When caring for a client who has acute respiratory distress syndrome (ARDS), the nurse elevates the head of the bed 30 degrees. What is the reason for this intervention? - correct answer To reduce abdominal pressure on the diaphragm Rationale: a semi-sitting position is the best position for matching ventilation and perfusion and for decreasing abdominal pressure on the diaphragm, so that the client can maximize breathing When assessing a mildly obese 35-year-old female client, the nurse is unable to locate the gallbladder when palpating below the liver margin at the lateral border of the rectus abdominal muscle. What is the most likely explanation for failure to locate the gallbladder by palpation? - correct answer The gallbladder is normal Rationale: a normal healthy gallbladder is not palpable A woman with an anxiety disorder calls her obstetrician's office and tells the nurse of increased anxiety since the normal vaginal delivery of her son three weeks ago. Since she is breastfeeding, she stopped taking her antianxiety medications, but thinks she may need to start taking them again because of her increased anxiety. What response is best for the nurse to provide this woman? - correct answer Inform her that some antianxiety medications are safe to take while breastfeeding Rationale: there are several antianxiety medications that are not contraindicated for breastfeeding mothers. An older male client with a history of type 1 diabetes has not felt well the past few days and arrives at the clinic with abdominal cramping and vomiting. He is lethargic, moderately, confused, and cannot remember when he took his last dose of insulin or ate last. What action should the nurse implement first? - correct answer Start an intravenous (IV) infusion of normal saline Rationale: the nurse should first start an intravenous infusion of normal saline to replace the fluids and electrolytes because the client has been vomiting, and it is unclear when he last ate or took insulin. The symptoms of confusion, lethargy, vomiting, and abdominal cramping are all suggestive of hyperglycemia, which also contributes to diuresis and fluid electrolyte imbalance. A client who received multiple antihypertensive medications experiences syncope due to a drop in blood pressure to 70/40. What is the rationale for the nurse's decision to hold the client's scheduled antihypertensive medication? - correct answer The additive effect of multiple medications has caused the blood pressure to drop too low Which client is at the greatest risk for developing delirium? - correct answer An adult client who cannot sleep due to constant pain. Which intervention should the nurse include in a long-term plan of care for a client with Chronic Obstructive Pulmonary Disease (COPD)? - correct answer Reduce risks factors for infection Which location should the nurse choose as the best for beginning a screening program for hypothyroidism? - correct answer A business and professional women's group A female client has been taking a high dose of prednisone, a corticosteroid, for several months. After stopping the medication abruptly, the client reports feeling "very tired". Which nursing intervention is most important for the nurse to implement? - correct answer Measure vital signs A male client reports the onset of numbness and tingling in his fingers and around his mouth. Which lab is important for the nurse to review before contacting the health care provider? - correct answer Serum calcium What explanation is best for the nurse to provide a client who asks the purpose of using the log-rolling technique for turning? - correct answer The technique is intended to maintain straight spinal alignment. A client receiving chemotherapy has severe neutropenia. Which snack is best for the nurse to recommend to the client? - correct answer Baked apples topped with dried raisins Which action should the school nurse take first when conducting a screening for scoliosis? - correct answer Inspect for symmetrical shoulder height. An unlicensed assistive personnel (UAP) assigned to obtain client vital signs reports to the charge nurse that a client has a weak pulse with a rate of 44 beat/ minutes. What action should the charge nurse implement? - correct answer Assign a practical nurse (LPN) to determine if an apical radial deficit is present After a sudden loss of consciousness, a female client is taken to the ED and initial assessment indicate that her blood glucose level is critically low. Once her glucose level is stabilized, the client reports that was recently diagnosed with anorexia nervosa and is being treated at an outpatient clinic. Which intervention is more important to include in this client's discharge plan? - correct answer Encourage a low-carbohydrate and high-protein diet A client with a peripherally inserted central catheter (PICC) line has a fever. What client assessment is most important for the nurse to perform? - correct answer Observe the antecubital fossa for inflammation. The nurse administers an antibiotic to a client with respiratory tract infection. To evaluate the medication's effectiveness, which laboratory values should the nurse monitor? Select all that apply - correct answer -White blood cell (WBC) count -Sputum culture and sensitivity A client is admitted to isolation with the diagnosis of active tuberculosis. Which infection control measures should the nurse implement? - correct answer Negative pressure environment A school nurse is called to the soccer field because a child has a nose bleed (epistaxis). In what position should the nurse place the child - correct answer Sitting up and leaning forward A young adult who is hit with a baseball bat on the temporal area of the left skull is conscious when admitted to the ED and is transferred to the Neurological Unit to be monitored for signs of closed head injury. Which assessment finding is indicative of a developing epidural hematoma? - correct answer Altered consciousness within the first 24 hours after injury. A female client with breast cancer who completed her first chemotherapy treatment today at an out-patient center is preparing for discharge. Which behavior indicates that the client understands her care needs - correct answer Rented movies and borrowed books to use while passing time at home Which instruction should the nurse provide a pregnant client who is complaining of heartburn? - correct answer Eat small meal throughout the day to avoid a full stomach. A client is admitted to the intensive care unit with diabetes insipidus due to a pituitary gland tumor. Which potential complication should the nurse monitor closely? - correct answer Hypokalemia Rational: pituitary tumors that suppress antidiuretic hormone (ADH) result in diabetes insipidus, which causes massive polyuria and serum electrolyte imbalances, including hypokalemia, which can lead to lethal arrhythmias A female client reports she has not had a bowel movement for 3 days, but now is defecating frequent small amount of liquid stool. Which action should the nurse implement? - correct answer Digitally check the client for a fecal impaction After changing to a new brand of laundry detergent, an adult male reports that he has a fine itchy rash. Which assessment finding warrants immediate intervention by the nurse? - correct answer Bilateral Wheezing. The nurse should teach the parents of a 6 year-old recently diagnosed with asthma that the symptom of acute episode of asthma are due to which physiological response? - correct answer Inflammation of the mucous membrane & bronchospasm A 10 year old who has terminal brain cancer asks the nurse, "What will happen to my body when I die?" How should the nurse respond? - correct answer "The heart will stop beating & you will stop breathing." The nurse is assessing a 3-month-old infant who had a pylorotomy yesterday. This child should be medicated for pain based on which findings? Select all that apply: - correct answer -Restlessness -Clenched Fist -Increased pulse rate -Increased respiratory rate. The nurse is preparing to administer an oral antibiotic to a client with unilateral weakness, ptosis, mouth drooping and, aspiration pneumonia. What is the priority nursing assessment that should be done before administering this medication - correct answer Determine which side of the body is weak. The nurse who is working on a surgical unit receives change of shift report on a group of clients for the upcoming shift. A client with which condition requires the most immediate attention by the nurse? - correct answer Abdominal-perineal resection 2 days ago with no drainage on dressing who has fever and chills. Rationale: the client with an abdominal- perineal resection is at risk for peritonitis and needs to be immediately assessed for other signs and symptoms for sepsis. The nurse is caring for a client who had gastric bypass surgery yesterday. Which intervention is most important for the nurse to implement during the first 24 postoperative hours? - correct answer Measure hourly urinary output. Rationale: a serious early complications of gastric bypass surgery is an anastomoses leak, often resulting in death. When preparing to discharge a male client who has been hospitalized for an adrenal crisis, the client expresses concern about having another crisis. He tells the nurse that he wants to stay in the hospital a few more days. Which intervention should the nurse implement? - correct answer Schedule an appointment for an out-patient psychosocial assessment. An adult female client tells the nurse that though she is afraid her abusive boyfriend might one day kill her, she keeps hoping that he will change. What action should the nurse take first? - correct answer Explore client's readiness to discuss the situation In caring for a client with Cushing syndrome, which serum laboratory value is most important for the nurse to monitor? - correct answer Glucose Azithromycin is prescribed for an adolescent female who has lower lobe pneumonia and recurrent chlamydia. What information is most important for the nurse to provide to this client - correct answer Use two forms of contraception while taking this drug. A client in the emergency center demonstrates rapid speech, flight of ideas, and reports sleeping only three hours during the past 48h. Based on these finding, it is most important for the nurse to review the laboratory value for which medication? - correct answer Divalproex. Rationale: divalproex is the first line of treatment for bipolar disorder BPD because it has a high therapeutic index, few side effects, and a rapid onset in controlling symptoms and preventing recurrent episodes of mania and depression. The serum value of divalproex should be determined since the client is exhibiting symptoms of mania, which may indicate non-compliance with the medication regimen A male client who is admitted to the mental health unit for treatment of bipolar disorder has a slightly slurred speech pattern and an unsteady gait. Which assessment finding is most important for the nurse to report to the healthcare provider? - correct answer Serum lithium level of 1.6 mEq/L or mmol/l (SI) Rationale: The therapeutic level of Serum lithium is 0.8 to 1.5 mEq/L or mmol/l (SI). Slurred speech and ataxia are sign of lithium toxicity A client was admitted to the cardiac observation unit 2 hours ago complaining of chest pain. On admission, the client's EKG showed bradycardia, ST depression, but no ventricular ectopy. The client suddenly reports a sharp increase in pain, telling the nurse, "I feel like an elephant just stepped on my chest" The EKG now shows Q waves and ST segment elevations in the anterior leads. What intervention should the nurse perform? - correct answer Administer prescribed morphine sulfate IV and provide oxygen at 2 L/min per nasal cannula. The nurse is developing a teaching program for the community. What population characteristic is most influential when choosing strategies for implementing a teaching plan? - correct answer Literacy level A client is being discharged with a prescription for warfarin (Coumadin). What instruction should the nurse provide this client regarding diet? - correct answer Eat approximated the same amount of leafy green vegetables daily so the amount of vitamin K consumed is consistent. A client who had a small bowel resection acquired methicillin resistant staphylococcus aureus (MRSA) while hospitalized. He treated and released, but is readmitted today because of diarrhea and dehydration. It is most important for the nurse to implement which intervention. - correct answer Maintain contact transmission precaution A postoperative female client has a prescription for morphine sulfate 10 mg IV q3 hours for pain. One dose of morphine was administered when the client was admitted to the post anesthesia care unit (PACU) and 3 hours later, the client is again complaining of pain. Her current respiratory rate is 8 breaths/minute. What action should the nurse take? - correct answer Administer Naxolone IV Which intervention is most important for the nurse to include in the plan of care for an older woman with osteoporosis? - correct answer Place the client on fall precautions Based on the information provided in this client's medical record during labor, which should the nurse implement? (Click on each chart tab for additional information. Please be sure to scroll to the bottom right corner of each tab to view all information contained in the client's medical record.) - correct answer Continue to monitor the progress of labor An unlicensed assistive personnel UAP leaves the unit without notifying the staff. In what order should the unit manager implement this intervention to address the UAPs behavior? (Place the action in order from first on top to last on bottom.) - correct answer 1. Note date and time of the behavior. 2. Discuss the issue privately with the UAP. 3. Plan for scheduled break times. 4. Evaluate the UAP for signs of improvement. A client with intestinal obstructions has a nasogastric tube to low intermittent suction and is receiving an IV of lactated ringer's at 100 ml/H. which finding is most important for the nurse to report to the healthcare provider? - correct answer Serum potassium level of 3.1 mEq/L or mmol/L (SI) Rationale: The normal potassium level in the blood is 3.5-5.0 milliEquivalents per liter (mEq/L). Which type of Leukocyte is involved with allergic responses and the destruction of parasitic worms? - correct answer Eosinophils Rationale: Eosinophils are involved in allergic responses and destruction of parasitic worms The healthcare provider prescribes the antibiotic cephradine 500mg PO every 6 hours for a client with a postoperative wound infection. Which foods should the nurse encourage this client to eat - correct answer Yogurt and/or buttermilk. Several months after a foot injury, and adult woman is diagnosed with neuropathic pain. The client describes the pain as severe and burning and is unable to put weight on her foot. She asks the nurse when the pain will "finally go away." How should the nurse respond? - correct answer Assist the client in developing a goal of managing the pain One day following an open reduction and internal fixation of a compound fracture of the leg, a male client complains of "a tingly sensation" in his left foot. The nurse determines the client's left pedal pulses are diminished. Based on these finding, what is the client's greatest risk? - correct answer Neurovascular and circulation compromise related to compartment syndrome The nurse is completing a head to be assessment for a client admitted for observation after falling out of a tree. Which finding warrants immediate intervention by the nurse? - correct answer Clear fluid leaking from the nose A client with multiple sclerosis (MS) has decreased motor function after taking a hot bath (Uhthoff's sign). Which pathophysiological mechanism supports this response - correct answer Temporary vasodilation While assessing a radial artery catheter, the client complains of numbness and pain distal to the insertion site. What interventions should the nurse implement? - correct answer Promptly remove the arterial catheter from the radial artery. A client is admitted with an epidural hematoma that resulted from a skateboarding accident. To differentiate the vascular source of the intracranial bleeding, which finding should the nurse monitor? - correct answer Rapid onset of decreased level of consciousness. The nurse finds a client at 33 weeks gestation in cardiac arrest. What adaptation to cardiopulmonary resuscitation (CPR) should the nurse implement? - correct answer Position a firm wedge to support pelvis and thorax at 30 degree tilt. When preparing a client for discharge from the hospital following a cystectomy and a urinary diversion to treat bladder cancer, which instruction is most important for the nurse to include in the client's discharge teaching plan? - correct answer Report any signs of cloudy urine output. For the past 24 hours, an antidiarrheal agent, diphenoxylate, has been administered to a bedridden, older client with infectious gastroenteritis. Which finding requires the nurse to take further action? - correct answer Tented skin turgor. After repositioning an immobile client, the nurse observes an area of hyperemia. To assess for blanching, what action should the nurse take? - correct answer Apply light pressure over the area. The nurse enters a client's room and observes the client's wrist restraint secured as seen in the picture. What action should the nurse take? - correct answer Reposition the restraint tie onto the bedframe. A female client with acute respiratory distress syndrome (ARDS) is chemically paralyzed and sedated while she is on as assist-control ventilator using 50% FIO2. Which assessment finding warrants immediate intervention by the nurse? - correct answer Diminished left lower lobe sounds Rationale: Diminished lobe sounds indicate collapsed alveoli or tension pneumothorax, which required immediate chest tube insertion to re-inflate the lung. The development of atherosclerosis is a process of sequential events. Arrange the pathophysiological events in orders of occurrence. (Place the first event on top and the last on the bottom) - correct answer 1. Arterial endothelium injury causes inflammation 2. Macrophages consume low density lipoprotein (LDL), creating foam cells 3. Foam cells release growth factors for smooth muscle cells 4. Smooth muscle grows over fatty streaks creating fibrous plaques 5. Vessel narrowing results in ischemia Following a motor vehicle collision, an adult female with a ruptured spleen and a blood pressure of 70/44, had an emergency splenectomy. Twelve hours after the surgery, her urine output is 25 ml/hour for the last two hours. What pathophysiological reason supports the nurse's decision to report this finding to the healthcare provider - correct answer Oliguria signals tubular necrosis related to hypoperfusion A nurse-manager is preparing the curricula for a class for charge nurses. A staffing formula based on what data ensures quality client care and is most cost-effective? - correct answer Skills of staff and client acuity When performing postural drainage on a client with Chronic Obstructive Pulmonary Disease (COPD), which approach should the nurse use? - correct answer Explain that the client may be placed in five positions A client presents in the emergency room with right-sided facial asymmetry. The nurse asks the client to perform a series of movements that require use of the facial muscles. What symptoms suggest that the client has most likely experience a Bell's palsy rather than a stroke? - correct answer Inability to close the affected eye, raise brow, or smile The nurse is teaching a client how to perform colostomy irrigations. When observing the client's return demonstration, which action indicated that the client understood the teaching? - correct answer Keeps the irrigating container less than 18 inches above the stoma The nurse should teach the client to observe which precaution while taking dronedarone? - correct answer Avoid grapefruits and its juic A client who sustained a head injury following an automobile collision is admitted to the hospital. The nurse include the client's risk for developing increased intracranial pressure (ICP) in the plan of care. Which signs indicate to the nurse that ICP has increased? - correct answer Confusion and papilledema Rationale: papilledema is always an indicator of increased ICP, and confusion is usually the first sign of increased ICP. Other options do not necessarily reflect increased ICP. The nurse is caring for a client receiving continuous IV fluids through a single lumen central venous catheter (CVC). Based on the CVC care bundle, which action should be completed daily to reduce the risk for infection? - correct answer Confirm the necessity for continued use of the CVC. During an annual physical examination, an older woman's fasting blood sugar (FBS) is determined to be 140 mg/dl or 7.8 mmol/L (SI). Which additional finding obtained during a follow-up visit 2 weeks later is most indicative that the client has diabetes mellitus (DM)? - correct answer Repeated fasting blood sugar (FBS) is 132 mg/dl or 7.4 mmol/L (SI). A new mother tells the nurse that she is unsure if she will be able to transition into parenthood. What action should the nurse take? - correct answer Determine if she can ask for support from family, friend, or the baby's father A client who was admitted yesterday with severe dehydration is complaining of pain a 24 gauge IV with normal saline is infusing at a rate of 150 ml/hour. Which intervention should the nurse implement first? - correct answer Stop the normal saline infusion. An elderly female is admitted because of a change in her level of sensorium. During the evening shift, the client attempts to get out bed and falls, breaking her left hip. Buck's skin traction is applied to the left leg while waiting for surgery. Which intervention is most important for the nurse to include in this client's plan care? - correct answer Ensure proper alignment of the leg in traction. An Unna boot is applied to a client with a venous stasis ulcer. One week later, when the Unna boot is removed during a follow-up appointment, the nurse observes that the ulcer site contains bright red tissue. What action should the nurse take in response to this finding? - correct answer Document the ongoing wound healing At the end of a preoperative teaching session on pain management techniques, a client starts to cry and states, "I just know I can't handle all the pain." What is the priority nursing diagnosis for this client? - correct answer anxiety The nurse note a visible prolapse of the umbilical cord after a client experiences spontaneous rupture of the membranes during labor. What intervention should the nurse implement immediately? - correct answer Elevate the presenting part off the cord A client who had a right hip replacement 3 day ago is pale has diminished breath sound over the left lower lung fields, a temperature of 100.2 F, and an oxygen saturation rate of 90%. The client is scheduled to be transferred to a skilled nursing facility (SNF) tomorrow for rehabilitative critical pathway. Based on the client's symptoms, what recommendation should the nurse give the healthcare provider? - correct answer Reassess readiness for SNF transfer. A client who is newly diagnosed with type 2 diabetes mellitus (DM) receives a prescription for metformin (Glucophage) 500 mg PO twice daily. What information should the nurse include in this client's teaching plan? (Select all that apply.) - correct answer -Recognize signs and symptoms of hypoglycemia. -Report persist polyuria to the healthcare provider. -Take Glucophage with the morning and evening meal. The nurse is developing an educational program for older clients who are being discharged with new antihypertensive medications. The nurse should ensure that the educational materials include which characteristics? Select all that apply - correct answer -Contains a list with definitions of unfamiliar terms -Uses common words with few Syllables -Uses pictures to help illustrate complex ideas During the admission assessment, the nurse auscultates heart sounds for a client with no history of cardiovascular disease. Where should the nurse listen when assessing the client's point of maximal impulse (PMI) (Click the chosen location. To change, click on a new location) - correct answer 4-5th intercostal space midclavicular An older male adult resident of long-term care facility is hospitalized for a cardiac catheterization that occurred yesterday. Since the procedure was conducted, the client has become increasingly disoriented. The night shift nurse reports that he attempted to remove the sandbag from his femoral artery multiple times during the night. What actions should the nurse take? (Select all that apply.) - correct answer -Notify the healthcare provider of the client's change in mental status. -Include q2 hour's reorientation in the client's plan of care. An older male comes to the clinic with a family member. When the nurse attempts to take the client's health history, he does not respond to questions in a clear manner. What action should the nurse implement first - correct answer Assess the surroundings for noise and distractions. The nurse caring for a client with acute renal fluid (ARF) has noted that the client has voided 800 ml of urine in 4 hours. Based on this assessment, what should the nurse anticipate that client will need? - correct answer Large amounts of fluid and electrolyte replacement. Which intervention should the nurse include in the plan of care for a child with tetanus? - correct answer Minimize the amount of stimuli in the room Suicide precautions are initiated for a child admitted to the mental health unit following an intentional narcotic overdose. After a visitor leaves, the nurse finds a package of cigarettes in the client's room. Which intervention is most important for the nurse to implement? - correct answer Remove cigarettes for the client's room A family member of a frail elderly adult asks the nurse about eligibility requirements for hospice care. What information should the nurse provide? (Select all that apply.) - correct answer -A client must be willing to accept palliative care, not curative care. ---The healthcare provider must project that the client has 6 months or less to live. A client with atrial fibrillation receives a new prescription for dabigatran. What instruction should the nurse include in this client's teaching plan? - correct answer Avoid use of [Show Less]
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